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Name: Date:
_______________________________________________________ ______________
Last First Middle
ARE YOU CERTIFIED BY THE FLORIDA DEPARTMENT OF HEALTH TO BE A 911
PUBLIC SAFETY TELECOMMUNICATOR IN THE STATE OF FLORIDA? Yes No
NOTICE: Please carefully read and follow these instructions exactly. Your ability to complete this
questionnaire, as instructed, will be evaluated and used as one basis for employment decisions. Declination or failure
to comprehensively provide the information requested throughout this document may result in your rejection or
disqualification. This document, when completed, will be used by the Fort Walton Beach Police Department as an
investigative aid. Assistance will be provided to those persons who may require a special accommodation.
INSTRUCTIONS:
• Answer every question as comprehensively as possible. If a question does not apply to you, so state with “N/A.”
• If the space available is insufficient to comprehensively answer a question, attach a separate sheet of 8½ x 11 paper.
Identify the section, page number and question number to the left of each questioned answered on a separate and
attached page. Annotate in the space provided in this questionnaire that the question is answered and/or continued on
an attached page.
• Do not misstate or omit any material fact since the statements made herein are subject to verification to determine your
qualifications for employment
• Answer all the questions accurately and completely.
• Before affixing your signature anywhere in this document, check to be sure that a Notary Public certification is not
required. If a Notary Public certification is required, you may bring the entire completed document to the Human
Resources Department to sign in the presence of a notary.
• Electronically scan and attach the completed document to your Communications Trainee application ONLINE.
“I have read and I understand all of the above instructions. I also understand that I will be
required to take a Certified Voice Stress Analysis examination to determine the truthfulness of the
information provided in this application.” Any untruthful statement made on this questionnaire
will result in disqualification of application or, if hired, immediate dismissal without appeal rights.
Signature of Applicant
_________________________________
Date
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I. PERSONAL
1. Full Name: _________________________________________________________________
Last First Middle
2. Alias(es), Nickname, Maiden Name: ___________________________________________
3. Have you ever had your name changed legally? Yes No
4. If you responded positively to question #3, indicate as follows:
A. Previous Name: ______________________________________________________
B. Date and Location of Change: ___________________________________________
C. Reason for change (include official document(s) concerning any change in name):
___________________________________________________________________
___________________________________________________________________
5. Place of Birth: City _____________________________________ State __________________
County _____________________________
6. Sex: _______, Weight: _______ lbs., Height: _______ ft _______in.,
Color Hair: _______ Color Eyes: _______
7. EEO Code: White Black Hispanic Asian
American Indian or Alaskan Native Other (Specify) __________________________
8. Social Security Number: __________-_____-__________
9. Scars, Tattoos and/or distinguishing marks: _______________________________________
____________________________________________________________________________
10. Are you a citizen of the United States? Yes No
Natural Born Naturalized
11. If naturalized citizen, check below if you are a citizen by virtue of Naturalization Certificate
issued to: Self Parent Spouse
12. Present Home Address: _________________________________________________________
City: _________________________, State: _____ Zip Code: ___________
13. How long have you lived at your present address? __________ Years, __________Months
14. With whom do your reside? _____________________________________________________
15. Home Telephone: (_______) _____ - __________
16. Business Telephone: (_______) _____ - __________
17. Chronologically list all previous places of residence during the last 5 years:
From: Month _______ Year _______ To: Month _______Year _______
Street Address: ___________________________________________________________________
City: ________________________ County: __________________ State: _____ Zip Code: _________
Landlord’s Name: ___________________________________________________________________
Landlord’s Address: __________________________________________________________________
Telephone: _______(area code)_____-__________ (number)
City: ________________________ County: __________________ State: _____ Zip Code: _________
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From: Month _______ Year _______ To: Month _______Year _______
Street Address: ___________________________________________________________________
City: ________________________ County: __________________ State: _____ Zip Code: _________
Landlord’s Name: ___________________________________________________________________
Landlord’s Address: __________________________________________________________________
Telephone: _______(area code)_____-__________ (number)
City: ________________________ County: __________________ State: _____ Zip Code: _________
From: Month _______ Year _______ To: Month _______Year _______
Street Address: ___________________________________________________________________
City: ________________________ County: __________________ State: _____ Zip Code: _________
Landlord’s Name: ___________________________________________________________________
Landlord’s Address: __________________________________________________________________
Telephone: _______(area code)_____-__________ (number)
City: ________________________ County: __________________ State: _____ Zip Code: _________
From: Month _______ Year _______ To: Month _______Year _______
Street Address: ___________________________________________________________________
City: ________________________ County: __________________ State: _____ Zip Code: _________
Landlord’s Name: ___________________________________________________________________
Landlord’s Address: __________________________________________________________________
Telephone: _______(area code)_____-__________ (number)
City: ________________________ County: __________________ State: _____ Zip Code: _________
18. Do you drink alcoholic beverages? Yes No
If “Yes”, what is your estimated monthly rate of consumption?
_____________________________
19. Do you gamble (inclusive of lotteries, bingo, organized gaming, sports betting, private parties,
etc..)? Yes No
If “Yes”, how much do you gamble on an average monthly basis? $ ___________
20 Have you ever used, tried, or experimented with marijuana/hashish? Yes No
If “Yes”, how many times and when was the last time? (Explain the circumstances): ________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
21. Have you ever used, tried, or experimented with ANY OTHER illegal drugs, cocaine (“crack”
or powder), opiates, barbiturates, amphetamines, hallucinogens, designer drugs, etc.?
Yes No
If “Yes”, how many times and when was the last time? (Explain the circumstances and
identify the drug(s):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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22. Have you ever taken ANY prescription medication(s) that were not specifically prescribed to
you? Yes No
If “Yes”, provide details inclusive of (1) the name(s) of the medication(s), (2) the individual
from whom you obtained the medication(s), the circumstances surrounding the incident(s) and
(4) whether or not you purchased the medication(s):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
23. Have you ever sold, delivered or otherwise transmitted ANY amount of ANY illegal drugs
(inclusive of but not limited to marijuana, cocaine, hallucinogens, hashish, or heroin, etc.)?
Yes No
If “Yes”, provide details inclusive of (1) the name(s) of the medication(s), (2) the individual
from whom you obtained the medication(s), (3) the circumstances surrounding the incident(s)
and (4) whether or not you purchased the medication(s):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
24. Have you ever sold, purchased, and/or delivered ANY prescription medication(s), which were
prescribed to you or to any other individual? Yes No
If “Yes”, provide details inclusive of (1) the name(s) of the medication(s), (2) the individual
from whom you obtained the medication(s), the circumstances surrounding the incident(s) and
(4) whether or not you purchased the medication(s):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
II. PERSONAL RELATIONSHIPS
1. If you are married, divorced or separated provide the following information:
a. Spouse’s Full Name: ____________________________________________________
Last First Middle
b. Maiden Name: ____________________________________________________
Last First Middle
c. Birth date: Month _______ Day _______ Year _______
d. Date of Marriage: Month _______ Day _______ Year _______
e. Location of Marriage: ___________________________________________________
(City, County, State)
25. Have you ever utilized, experimented with, sold, delivered or purchased ANY anabolic
steroids? Yes No
If “Yes”, provide details inclusive of (1) the name(s) of the steroid(s), (2) the individual from
whom you obtained the steroid(s), the circumstances surrounding the incident(s) and (3)
whether or not you purchased the steroid(s):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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2. Are you presently living with your spouse? Yes No
If “No”, spouse’s current address:
___________________________________________________________
(City, County, State)
3. List spouse’s occupation and place of employment: ___________________________________
____________________________________________________________________________
4. Are you currently living with someone whom you consider to be a girl/boyfriend? Yes No
If “Yes”, please provide the following information:
a. Girl/boy friend’s Full Name: ______________________________________________
Last First Middle
b. Birth date: _____________________ Month _______ Day _______ Year _______
c. Occupation: __________________________________________________________
5. Have you ever been involved in an unreported physical confrontation with your spouse, former
spouse, boy/girlfriend, former boy/girlfriend, or a relative (including in-laws and former in-
laws)? Yes No
If “Yes”, provide details including (1) approximate date(s), (2) with whom the confrontation(s)
occurred, (3) the circumstances surrounding the confrontation(s), (4) the location(s) of the
confrontation(s), and (5) any injuries resulting from the confrontation(s):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
6. Have you ever been involved in a physical confrontation with your spouse, former spouse,
boy/girlfriend, former boy/girlfriend, or a relative (including in-laws and former in-laws) that
was reported to a law enforcement agency? Yes No
If yes provide details including (1) approximate date(s), (2) with whom the confrontation(s)
occurred, (3) the circumstances surrounding the confrontation(s), (4) the location(s) of the
confrontation(s), (5) the law enforcement agency(ies) responding, and (6) any injuries resulting
from the confrontation(s):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
7. Have you ever been involved in any other incident(s) of domestic altercation(s), domestic
violence, or stalking not specifically mentioned? If “Yes”, provide details:
____________________________________________________________________________
____________________________________________________________________________
8. Have you ever been served with, or had filed against you, a restraining order, an injunction for
protection against repeat violence, an injunction for protection against domestic violence or
any other injunction? Yes No
If “Yes”, provide details:
____________________________________________________________________________
____________________________________________________________________________
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9. Have you ever participated, voluntarily or involuntarily, in any domestic violence counseling,
marriage counseling, or anger management? Yes No
If “Yes”, provide details:
___________________________________________________________________________
III. EDUCATION
1. List all high schools attended (include copies of any diplomas):
Name
Location
Dates Attended
From To
Years
Completed
Graduate
Yes No
2. Other schools/training (trade, vocational, business or military):
Name of School
and Location
Dates Attended
From To
Courses/Studies
Certificate
Yes No
4. Were you ever expelled or suspended from ANY SCHOOL, or were you ever disciplined by
any school official? Yes No
If “Yes”, provide details:
____________________________________________________________________________
3. List all colleges or universities attended (include official transcripts):
Name/Location of
College/University
Dates Attended
From To
Credit Hours
Sem. Quar.
Degree
Received
Year
Received
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IV. LANGUAGES OTHER THAN ENGLISH:
1. Enter language and indicate your knowledge of each by placing an “X” or “✓” in the proper
column.
Language
Reading
Ex Good Fair
Speaking
Ex Good Fair
Understanding
Ex Good Fair
Writing
Ex Good Fair
V. SPECIAL QUALIFICATIONS AND SKILLS:
1. Indicate special skills/licenses you possess (pilot, radio operator, machines, equipment,
computer, etc.). (Licenses: Show licensing authority, where first issued, and date the current
license expires.)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
2. Indicate special qualifications not covered in the application. For example, your most
important publications (do not submit copies unless requested), your patents or inventions,
public speaking and publications experience, membership in professional or scientific societies,
civic or fraternal organizations, and honors and fellowships received:
____________________________________________________________________________
____________________________________________________________________________
VI. MILITARY INFORMATION:
1. Have you ever served in a military organization of the United States? Yes No
If “Yes”, give period of active military service and other data requested:
From: Month _______ Year _______ To: Month _______Year _______
Branch of Service: _______________________________________
Highest Rank Achieved: ________________________
Unit: _______________________________________
Type of Discharge Received: _______________________________________
Reason for Discharge: _______________________________________
2. Are you now an active member of any branch of the United States Military? Yes No
If “Yes”, indicate whether it is a United States Reserve Force or State National Guard along
with other data requested:
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From: Month _______ Year _______ To: Month _______Year _______
Branch of Service: _______________________________________
Serial Number:_______-_____-_______Rank: _______________________________________
Unit: _______________________________________
Separation date: Month _______ Day _______ Year _______
3. Were you ever tried, punished, reprimanded, or reduced in rank for any infraction of military
rules and regulations? Yes No
If “Yes”, indicate the (1) dates, (2) charges against you, (3) type of court-martial or other
disciplinary proceeding, and (4) the disposition of charges:
____________________________________________________________________________
____________________________________________________________________________
4. Has your discharge or separation ever been corrected or changed? Yes No
If “Yes” provide details:
Changed from: __________________________ To: __________________________________
Authority: _______________________________________________
Details: ______________________________________________________________________
___________________________________________________________________________
VII. EMPLOYMENT:
1. What is your current occupation: ______________________________________
2. Have you EVER been discharged, terminated, fired or asked and/or forced to resign from any
place of employment because of misconduct or unsatisfactory service or for any other reason
(except military)? Yes No
If “Yes” explain, giving name and address of employer, approximate date and reason in each
case:
____________________________________________________________________________
____________________________________________________________________________
3. Do you object to wearing a uniform? Yes No
4. Do you object to working varying shifts, i.e. rotating days and nights? Yes No
5. Have you ever received unemployment insurance/compensation or other Federal, State, or
Local benefits of assistance? Yes No
How many times? (Provide documentation): ________________
Are you currently receiving unemployment benefits? Yes No
If “Yes” to either question, provide details (inclusive of dates):
____________________________________________________________________________
____________________________________________________________________________
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6. Have you EVER received disciplinary counseling, an oral or written reprimand, suspension, or
any other disciplinary action during ANY term of employment? Yes No
If “Yes”, provide details:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
7. List ALL of the previous FIVE jobs you have held. List ANY and ALL jobs held by you at a law enforcement,
correctional or other criminal justice agency (sworn and/or non-sworn), regardless of when it was. Place your
present or most recent job FIRST. If you need more space, you may include additional sheets. Include military
service and all periods of unemployment in proper time sequence. List all part-time, temporary, seasonal, and
voluntary jobs.
Do you object to your present employer being contacted? Yes No
Name of Employer: ___________________________________________________________________
Street Address: ______________________________________________________________________
City: ________________________ County: __________________ State: _____ Zip Code: _________
Telephone: (_______) _____-__________ Job Title: ______________________________________
Description of Duties : ________________________________________________________________
___________________________________________________________________________________
Supervisor’s Name: _______________________________ Part Time Full Time
Dates of Employment: Month _______ Year _______ To: Month _______Year _______
Why did you leave? ________________________________________________________________
Name of Employer: ___________________________________________________________________
Street Address: ______________________________________________________________________
City: ________________________ County: __________________ State: _____ Zip Code: _________
Telephone: (_______) _____-__________ Job Title: ______________________________________
Description of Duties : ________________________________________________________________
___________________________________________________________________________________
Supervisor’s Name: _______________________________ Part Time Full Time
Dates of Employment: Month _______ Year _______ To: Month _______Year _______
Why did you leave? ________________________________________________________________
Name of Employer: ___________________________________________________________________
Street Address: ______________________________________________________________________
City: ________________________ County: __________________ State: _____ Zip Code: _________
Telephone: (_______) _____-__________ Job Title: ______________________________________
Description of Duties : ________________________________________________________________
___________________________________________________________________________________
Supervisor’s Name: _______________________________ Part Time Full Time
Dates of Employment: Month _______ Year _______ To: Month _______Year _______
Why did you leave? ________________________________________________________________
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Name of Employer: ___________________________________________________________________
Street Address: ______________________________________________________________________
City: ________________________ County: __________________ State: _____ Zip Code: _________
Telephone: (_______) _____-__________ Job Title: ______________________________________
Description of Duties : ________________________________________________________________
___________________________________________________________________________________
Supervisor’s Name: _______________________________ Part Time Full Time
Dates of Employment: Month _______ Year _______ To: Month _______Year _______
Why did you leave? ________________________________________________________________
Name of Employer: ___________________________________________________________________
Street Address: ______________________________________________________________________
City: ________________________ County: __________________ State: _____ Zip Code: _________
Telephone: (_______) _____-__________ Job Title: ______________________________________
Description of Duties : ________________________________________________________________
___________________________________________________________________________________
Supervisor’s Name: _______________________________ Part Time Full Time
Dates of Employment: Month _______ Year _______ To: Month _______Year _______
Why did you leave? ________________________________________________________________
13. Have you EVER had a sexual harassment complaint, FORMAL OR INFORMAL, filed
against you, or have you ever participated in any form of activity that may be considered
sexual harassment, or have you ever been informally accused of sexual harassment?
Yes No
If “Yes”, provide details including (1) the name(s) of the complainant(s), (2) the nature of the
complaint(s), (3) the date(s), time(s) and location(s) of the complaint(s), and (4) the result(s) of
the
complaint(s):_______________________________________________________________
____________________________________________________________________________
14. Have you ever given/received any special considerations, promotions or any other benefits in
the work place in exchange for sexual favors? Yes No
If “Yes”, provide details: ________________________________________________________
____________________________________________________________________________
15. Have you ever been the victim of sexual harassment? Yes No
16. Are there any incidents in your life not mentioned herein which may reflect upon your
suitability to perform the duties which may be required of you in a law enforcement capacity or
which might require further explanation? Yes No
If “Yes”, provide details: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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VIII. FINANCIAL HISTORY
1. Have you ever filed bankruptcy? Personal: Yes No
Business: Yes No
If “Yes”, provide details: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
2. Have you ever had accounts placed in the hands of a collection agency? Yes No
If “Yes”, provide details: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
3. Are you responsible for child support payments? Yes No
If “Yes”, how much monthly? $ ___________
If “Yes”, are your payments current? Yes No
If “No”, provide details: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4. If you have EVER BEEN responsible for paying child support, have you ever been in arrears?
Yes No
If “Yes”, provide details: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
5. If you are responsible for making child support payments, has legal action ever been taken
against you for either failing to make payments or delaying payments? Yes No
If “Yes”, provide details: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
6. a. List any business you or your spouse have a financial interest in:
Business
Amount
of Interest
Yearly Income
Name and Address
of Partners
b. Of these businesses, do any currently have a contract with the City of Fort Walton
Beach? Yes No
If “Yes”, provide details: _______________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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IX. CRIMINAL INVOLVEMENT AND JUVENILE RECORD
(Arrest, Detention, and Litigation - show all arrests including juvenile and traffic arrests)
Please be advised that as a criminal justice applicant, you must reveal all arrests and
convictions REGARDLESS of sealed, expunged or juvenile status. Per Florida Statute
943.058 you may not lawfully deny arrests or convictions, notwithstanding adjudication being
withheld or the sealing or expungement of arrest/conviction records. Misdemeanor arrests
and/or convictions may not necessarily disqualify you for criminal justice employment.
1. Have you ever been arrested or detained by ANY law enforcement agency? Yes No
If “Yes” provide details. Also provide police and court records if available (include any arrest
in which the records were expunged).
Crime(s) Charged: ______________________________________________
Date of Arrest: Month _______ Day _______ Year _______
Plea Entered: Guilty Not Guilty Nolo-Contendre Other (specify) ___________
Disposition: Guilty Not Guilty Adjudication Withheld Other (specify) _________
Sentence: ______________________________________________
Arresting Agency: ______________________________________________
Street Address: _______________________________ City: __________________________
County: _______________________________ State: _____ Zip Code: __________
Crime(s) Charged: ______________________________________________
Date of Arrest: Month _______ Day _______ Year _______
Plea Entered: Guilty Not Guilty Nolo-Contendre Other (specify) ___________
Disposition: Guilty Not Guilty Adjudication Withheld Other (specify) _________
Sentence: ______________________________________________
Arresting Agency: ______________________________________________
Street Address: _______________________________ City: __________________________
County: _______________________________ State: _____ Zip Code: __________
Crime(s) Charged: ______________________________________________
Date of Arrest: Month _______ Day _______ Year _______
Plea Entered: Guilty Not Guilty Nolo-Contendre Other (specify) ___________
Disposition: Guilty Not Guilty Adjudication Withheld Other (specify) _________
Sentence: ______________________________________________
Arresting Agency: ______________________________________________
Street Address: _______________________________ City: __________________________
County: _______________________________ State: _____ Zip Code: __________
2. Have you ever been served with a criminal summons or notice to appear; or has a criminal
summons or notice to appear ever been issued in your name? Yes No
If “Yes”, provide details:
Crime(s) Charged: ______________________________________________
Date of Service: Month _______ Day _______ Year _______
Plea Entered: Guilty Not Guilty Nolo-Contendre Other (specify) ___________
Disposition: Guilty Not Guilty Adjudication Withheld Other (specify) _________
Sentence: ______________________________________________
Serving Agency: ______________________________________________
Street Address: _____________________________ City: _____________________________
County: _______________________________ State: _____ Zip Code: __________
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3. Have you ever been served with a trespass warning notice: Yes No
If “Yes”, provide details: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4. What is the least expensive item you have ever stolen? (Provide details inclusive of (1) the
value of the item, (2) from whom was the item stolen, (3) if the item was returned, and (4)
approximate date and location of the theft):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
a. Were you caught and/or punished for the theft? Yes No
If “Yes” by whom? _______________________________________
b. Was the item(s) returned to the owner? Yes No
5. What is the most expensive item you have ever stolen? (Provide details inclusive of (1) the
value of the item, (2) from whom was the item stolen, (3) if the item was returned, and (4)
approximate date and location of the theft):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
a. Were you caught and/or punished for the theft? Yes No
If “Yes” by whom? _______________________________________
b. Was the item(s) returned to the owner? Yes No
6. Have you ever stolen or embezzled money, merchandise or equipment from an employer?
Yes No
If “Yes”, provide details inclusive of (1) from what employer, (2) the approximate date and
location of the incident(s), and the value of the money and/or merchandise and/or equipment:
____________________________________________________________________________
____________________________________________________________________________
a. Were you caught and/or punished for the theft? Yes No
If “Yes” by whom? _______________________________________
b. Was the item(s) returned to the owner? Yes No
7. When was the last time you stole anything? Provide details inclusive of (1) from what whom,
(2) the approximate date and location of the incident(s), and the value of the money and/or
merchandise and/or equipment:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
a. Were you caught and/or punished for the theft? Yes No
If “Yes” by whom? _______________________________________
b. Was the item(s) returned to the owner? Yes No
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8. Have you ever committed, been a suspect in, accused of, or investigated by any law
enforcement agency or any social service agency for child neglect, child abuse, child sexual
abuse, child exploitation, or child sexual exploitation? Yes No
If “Yes”, provide details including (1) the agency conducting the investigation, (2) the nature of
the investigation, (3) the location and approximate date of the investigate offense, and (4) the
disposition of the investigation (Provide copies of law enforcement or social services report(s):
____________________________________________________________________________
____________________________________________________________________________
9. Have you ever received, purchased or viewed any printed materials, photographs, video tapes,
movies, or any other form of media, containing child pornography or what may be considered
child pornography by society in general? Yes No
If “Yes”, provide details including (1) the source(s) of the material(s) or media, (2) and the
approximate date(s) and location(s) of the incident(s): _________________________________
____________________________________________________________________________
____________________________________________________________________________
10. Have you ever committed, been a suspect in, accused of, or investigated for any offense
relating to rape, statutory rape, “date rape”, lewd and/or lascivious behavior or sexual battery?
Yes No
If “Yes”, provide details including (1) the approximate date(s) and location(s) of the
incident(s), (2) the investigating law enforcement agency(ies) if applicable (provide copies of
any reports):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
11. Have you ever committed, been a suspect in, accused of, or investigated for any offense
relating to exposure of sexual organs and/or indecent exposure? Yes No
If “Yes”, provide details including (1) the approximate date(s) and location(s) of the
incident(s), (2) the investigating law enforcement agency(ies) if applicable (provide copies of
any reports):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
12. Have you ever, as an adult (over the age of eighteen), had or participated in any sexual activity
and/or relations with an individual considered to be a minor (under the age of eighteen)?
Yes No
If ”Yes”, provide details inclusive of: (1) the age(s) of the minor(s) and your age at the time of
the incident(s) and (2) the date(s) and location(s) of the incident(s):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
13. Have you ever been placed on probation? Yes No
If “Yes”, provide details: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
15
14. Have you ever been required to pay a court fine other than traffic? Yes No
If “Yes” provide details: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
16. Is there anything that you have ever been involved in that is not specifically mentioned or
disclosed herein that may be considered criminal activity: Yes No
If “Yes”, provide complete details, including jurisdiction, date(s), location(s) and outcome(s):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
17. If you have ever been fingerprinted by a law enforcement agency for any reason, give details
below. Your answer will be checked with the F.B.I. and other agencies.
Agency: ______________________________ Date: Month _______ Day _______ Year _______
Purpose: __________________________________________________
Agency: ______________________________ Date: Month _______ Day _______ Year _______
Purpose: __________________________________________________
Agency: ______________________________ Date: Month _______ Day _______ Year _______
Purpose: __________________________________________________
18. Have you ever been advised of your Miranda Rights? Yes No
If “Yes” provide details: ________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
19. Have you ever been the subject of a police criminal investigation? Yes No
If “Yes” provide details: ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
20. Have you ever had a polygraph or CVSA examination? If yes, list: Yes No
Date Examiner’s Name Purpose Results
21. Has any member of your immediate family ever been arrested or convicted of a criminal
offense? If “Yes”, provide the following information: Yes No
Name Relationship Offense Where Arrested Date
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X. VEHICLE OPERATOR’S LICENSE
1. Do you now possess a valid driver’s license from the State of Florida? Yes No
If “Yes” provide Driver’s License Number: _______-_______-_____-________-_____
Expiration Date: Month _______ Day _______ Year _______
Current status of license: Valid Suspended
2. Do you now, or have you ever, possessed a driver’s license issued by any state other than
Florida? Yes No
If “Yes” provide the following:
State: _____ Driver’s License Number: ___________________________________________
Expiration Date: Month _______ Day _______ Year _______
Current status of license: Valid Suspended
State: _____ Driver’s License Number: ___________________________________________
Expiration Date: Month _______ Day _______ Year _______
Current status of license: Valid Suspended
3. Was your driver’s license ever restricted, suspended or revoked? Yes No
If “Yes” provide details (inclusive of reason and length(s)):
____________________________________________________________________________
____________________________________________________________________________
4. Was your license ever restored? Yes No
If “Yes” provide date: Month _______ Day _______ Year _______
5. List below all traffic citations you have received:
Location
(Street, City, State)
Approximate
Date
Nature of Violation
Penalty or
Disposition
6. Have you ever been involved in a motor vehicle accident? Yes No
If “Yes”, provide details for each accident, whether collision, non-collision or hit and run:
Date: Month _______ Day _______ Year _______ Injury Non-Injury
Police Investigation? Yes No
Location: ___________________________________________________________________________
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Cause of Accident (ran red light, careless driving, etc.): ______________________________________
Who was indicated “at fault”? ______________________________________
Date: Month _______ Day _______ Year _______ Injury Non-Injury
Police Investigation? Yes No
Location: ___________________________________________________________________________
Cause of Accident (ran red light, careless driving, etc.): ______________________________________
Who was indicated “at fault”? ______________________________________
XI. CHARACTER REFERENCES
Do not include relatives, former employers, or persons living outside the United States or its territories.
List only character references who have a definite knowledge of your qualifications and fitness for the
position for which you are applying. Do not repeat names of supervisors. List 4 character references.
Name of Character
Reference
Years
Known
Address
(Street, City, State, Zip)
Phone Number
Business Home
XII. NEIGHBORS
Provide the names, addresses and telephone numbers for a minimum of 3 current neighbors. If you
have resided at your present address for less than 1 year, provide a listing of an additional 3 neighbors
for your last previous address. In addition, if you reside in an apartment, provide the name, address and
telephone number for your current landlord.
Name of Neighbor Address
(Street, City, State, Zip)
Phone Number
Business Home
1. List any current or former members of the Fort Walton Beach Police Department with whom
you are acquainted: ___________________________________________________________
____________________________________________________________________________
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2. List any members of other law enforcement agencies with whom you are acquainted and the
agency: _____________________________________________________________________
______________________________________________________________________
XIII. SOCIAL MEDIA
List all of your online Social Media Accounts (including Alias Accounts):
Handle/ID: _______________________________ Platform: ________________________
Handle/ID: _______________________________ Platform: ________________________
Handle/ID: _______________________________ Platform: ________________________
All candidates must produce the below listed ORIGINAL documents prior to this application being processed.
FWBPD USE ONLY
__________ Birth Certificate
__________ High School Diplomas of GED Equivalency
__________ College Diploma or Transcripts (if attended)
__________ Other Schools and/or Courses
__________ Armed Forces Discharge and DD214
__________ Naturalization papers
__________ Valid Driver’s License
__________ Florida Police Standards Minimum Standards Certificate and Test Scores
__________ Social Security Card
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THE FOLLOWING IS TO BE EXECUTED PRIOR TO SUBMISSION AND IN THE PRESENCE OF A
NOTARY PUBLIC:
I hereby swear or affirm that there are no misrepresentations or omissions in or falsifications of the
above statements and answers to questions. I am aware that should investigation disclose such
misrepresentations, falsifications, or omissions, my application will be rejected and I will be disqualified
from applying in the future for any position in the service of the Fort Walton Beach Police Department,
or, if after my acceptance for employment, subsequent investigation should disclose misrepresentation,
falsifications, or omissions, it will be just cause for immediate dismissal.
__________________________________________ __________________
Signature of Applicant Date
Sworn to and subscribed before me this _______ day of _____________________, 20_____
_________________________________
State of Florida
(Signature of Notary Public) __________________________________________________ (Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known OR Produced Identification
Type of Identification ___________________________________